The purpose of this invention is to provide a simple breathing circuit that can, for example, be added to a standard circle anaesthetic circuit known to persons skilled in the art to hasten recovery of patients administered vapour anaesthetics prior to an operation.
This invention also relates to the use of the breathing circuit in hastening the recovery of patients who have been administered vapour anaesthetics prior to a surgical operation.
This invention also relates to methods of treatment of patients to hasten their recovery from administration of the vapour anaesthetics to them prior to surgical procedures.
Physiology
Venous blood returns to the heart from the muscles and organs depleted of oxygen (O2) and full of carbon dioxide (CO2). Blood from various parts of the body is mixed in the heart (mixed venous blood) and pumped to the lungs. In the lungs the blood vessels break up into a net of small vessels surrounding tiny lung sacs (alveoli). The net of vessels surrounding the alveoli provides a large surface area for the exchange of gases by diffusion along their concentration gradients. A concentration gradient exists between the partial pressure of CO2 (PCO2) in the mixed venous blood (PvCO2) and the alveolar PCO2. The CO2 diffuses into the alveoli from the mixed venous blood from the beginning of inspiration until an equilibrium is reached between the PvCO2 and the alveolar PCO2 at some time during the breath. When the subject exhales, the end of his exhalation is considered to have come from the alveoli and reflect the equilibrium concentration between the capillaries and the alveoli; the PCO2 in this gas is called end-tidal PCO2 (PETCO2).
When the blood passes the alveoli and is pumped by the heart to the arteries it is known as the arterial PCO2 (PaCO2). The arterial blood has a PCO2 equal to the PCO2 at equilibrium between the capillaries and alveoli. With each breath some CO2 is eliminated and fresh air containing little CO2 (assumed to be O) is inhaled and dilutes the residual alveolar PCO2, establishing a new gradient for CO2 to diffuse out of the mixed venous blood into the alveoli. The rate of breathing, or ventilation (V), usually expressed in L/min, is exactly that required to eliminate the CO2 brought to the lungs and maintain an equilibrium PCO2 (and PaCO2) of approximately 40 mmHg (in normal humans). When one produces more CO2 (e.g. as a result of fever or exercise), more CO2 is produced and carried to the lungs. One then has to breathe harder (hyperventilate) to wash out the extra CO2 from the alveoli, and thus maintain the same equilibrium PaCO2. But if the CO2 production stays normal, and one hyperventilates, then the PaCO2 falls.
It is important to note that not all V contributes to blowing off CO2. Some V goes to the air passages (trachea and bronchi) and alveoli with little blood perfusing them, and thus doesn""t contribute to blowing off CO2. That portion of V that goes to well perfused alveoli and participates in gas exchange is called the alveolar ventilation (VA).
There are a number of circumstances in therapeutic medicine and research where we want the subject to breathe harder but not change his PaCO2 (see Table 1).
Table 1:
Title: Summary of previous studies attempting to maintain constant PETCO2 during hyperpnea
Legend: Method of adjustment of inspired PCO2: M=manual; A=automated. Source of CO2: R=rebreathing; E=external.
1. Angell-James, J. E., Clarke, J. A., de Burgh Daly, M. and Taton, A., Carotid chemoreceptor function and structure in the atherosclerotic rabbit: respiratory and cardiovascular responses to hyperoxia and hypercapnia. Cardiovascular Research 23(6): 541-53, 1989.
2. Belman, M. J. and C. Mittman. Ventilatory muscle training improves exercise capacity in chronic obstructive pulmonary disease patients. Am. Rev. Respir. Dis. 121:273-280, 1980.
3. Bradley, M. E. and Leith, D. E. Ventilatory muscle training and the oxygen cost of sustained hyperpnea. J. Appl. Physiol. 45(6):885-892, 1978.
4. Busija, D. W., Orr, J. A., Rankin, J. G. H., Liang, H. K. and Wagerle, L. C., Cerebral blood flow during normocapnic hyperoxia in the unanaesthetized pony. J. Apple. Physiol. 48(1):10-15, 1980.
5. Jonsson, L. O. Predictable PaCO2 with two different flow settings using the Mapleson D. system. Acta Anaesthesiol Scand. 34:237-240, 1990.
6. McKerrow, C. B., and Otis, A. B. Oxygen cost of hyperventilation. J. Apple. Physiol. 9:375-79, 1956.
7. Robbins, P. A., Swanson, G. D. and Howson, M. G. A prediction-correction scheme for forcing alveolar gases along certain time courses. J. Apple. Physiol. 52(5):1353-1357, 1982.
8. Smith, D. M., Mercer, R. R. and Eldridge, F. L., Servo control of end-tidal CO2 in paralyzed animals. J. Apple. Physiol. 45(1):133-136, 1978.
9. Somers, V. K., Mark, A. L., Zavala, D. C. and Abboud, F. M. Influence of ventilation of hypocapnia on sympathetic nerve responses to hypoxia in normal humans. J. Appl. Physiol. 67(5):2095-2100, 1989.
10. Sorkness, R. and Vidruk, E. Reflex effects of isocapnic changes in ventilation of tracheal tone in awake dogs. Respir. Physiol. 69:161-172, 1987.
11. Tenney, S. M. and Reese, R. E. The ability to sustain great breathing efforts. Respir. Physiol. 5:187-201, 1968.
12. Wahba, R. W. M. and Tessler, M. J. Misleading end-tidal CO2 tensions. Can. J. Anaesth. 43(8):862-6, 1996.
This requires compensating for excess ventilation by inhaling CO2 either from exhaled gas or some external source. The amount of CO2 required to be inhaled needs to be adjusted manually or by an automated servo-controlled mechanism, depending on how fine the control of PaCO2 is required. The input signal is the PETCO2. Stability of PaCO2 depends on the variability of CO2 production and ventilation on the one hand, and the ability of a system to compensate for this variability on the other.
The termination of the anaesthetic effects of intravenously administered drugs depends on metabolism and redistribution. The recovery time from anaesthesia is therefore determined by the drug""s pharmacology and cannot be accelerated.
This is not so for inhaled anaesthetic vapours. The uptake and elimination of anaesthetic vapours is predominantly through the lungs. The partial pressure of an anaesthetic vapour in the blood going to the brain is dependent upon the equilibration of vapour between the blood and the lungs. The concentration of vapour in the lungs in turn is dependent on the concentration of vapour in the inhaled gas, the rate of breathing, and the rate of transfer of gas between the lung and the blood. The newer anaesthetic agents desflurane and sevoflurane have very low blood solubility. Therefore the amount of drug transferred between the lungs and the blood is small and can, for discussion purposes, be ignored. Thus, for a patient waking up from a vapour anaesthetic, the greater the rate of breathing, the more vapour is eliminated from the lungs. However, in anaesthetized patients breathing spontaneously, ventilation is often depressed as a result of combined effects of residual intravenously administered anaesthetic drugs, pain relieving drugs (i.e. narcotics), the effects of surgery, as well as the respiratory depressant effect of the residual anaesthetic vapour itself
Practically, there has been limited scope for intervention to hasten the process of eliminating vapour from the lung and thus hastening the rate of emergence from the effects of vapour anaesthesia.
1. Artificial Ventilation
Manually or mechanically hyperventilating patients at the end of surgery is generally ineffective in shortening the time of recovery from anaesthesia.
a) High ventilation using the circle anaesthetic circuit results in rebreathing of exhaled gases. These gases contain anaesthetic vapour as well as CO2. The CO2 is eliminated by the CO2 absorber in the circuit, but the exhaled anaesthetic vapour is returned to the patient.
b) The attempts at hyperventilation will result in a decrease in arterial PCO2. The low arterial PCO2 removes the stimulus to breathe, which in turn delays elimination of vapour (and may also prevent adequate oxygenation of the blood).
This is seldom practised.
2. Flushing the Circuit:
High fresh gas flows in the circuit are inefficient in washing out the vapour from the circuits. The circle anaesthetic circuits have volumes of approximately 8 L (not counting the patient""s lung volume of approximately 2.5 L). At the maximum fresh gas flows on the oxygen flow meter of 10 L/min, it would take about 4 minutes to wash out the anaesthetic vapour from the circuit alone!
3. Stimulate breathing
In the past, some anaesthetists tried to stimulate the patient""s breathing by adding CO2 to the breathing circuit. The rationale was to increase the CO2 concentration in the circuit, stimulate the patient to breathe harder until he managed to ventilate off the CO2 and some of the vapour as well. This has largely been abandoned and has been labeled a wasteful and dangerous practice.
a) It is wasteful for the reasons enumerated in 1a and 1b (vide supra). As well, the practice is wasteful in that extra CO2 absorbing crystals are consumed.
b) The technique may put a patient at risk if the patient cannot respond to the extra CO2 by increasing their ventilation. They will absorb it and develop a high blood CO2 concentration which can be detrimental. The high CO2 in the patient also causes them a good deal of distress on waking up as it makes them feel like they are not getting enough air to breathe.
4. Increase ventilation, keeping PCO2 constant
To increase the ventilation without lowering PCO2 requires adding CO2 to the circuit. This can be supplied from an external source or from the subject""s exhaled gas. All the presently described systems depend on a servo-controlled system, or feedback loop to regulate the amount of CO2 supplied to the patient. These devices are complex, cumbersome and expensive. No such device has been reported used for hastening the elimination of anaesthetic vapour during recovery from anaesthesia. With respect to 4 above, there are considerable limitations of servo-controlled methods, both manual or automatic. These may be discussed as follows:
1. Input Signal
Whereas the parameter that we want to keep constant is the arterial PCO2, feedback systems use the CO2 concentration in the expired-gas, the so called end tidal PCO2 (PETCO2) as the input signal and endpoint. The PETCO2 can be very different from the arterial PCO2 in many circumstances. Furthermore, changes in PETCO2 may not correlate with those in arterial PCO2. This will result in PETCO2 being an inappropriate input for the control of arterial PCO2. For example, a smaller than usual breath decreases PETCO2 (tending to increase arterial PCO2), causing a servo-controller to respond with an inappropriate increase in inspired CO2.
2. Gain
If, in an attempt to obtain fine control, the gain in a servo-control system is set too high, the response becomes unstable and may result in oscillation of the control variable. Conversely, if the gain is set too low, compensation lags. Over-damping of the signal results in a the response never reaching the target. To address these problems, servo-controllers require complex algorithms and expensive equipment.
3. Inherent limitation
Servo-control systems work on the principle of detecting, and subsequently attempting to correct for, changes in PETCO2. Even under ideal conditions, no such system can predict the size of an impending VT in a spontaneously breathing subject and thus deliver the appropriate CO2 load.
As is apparent, people have tried to hasten the recovery of patients who have been anaesthetized and have made substantial efforts in this regard. However, they have been, for the most part, as seen above, unsuccessful. The reason for the attempts is that the benefits of faster return to consciousness, the less the need for recovery care and the less risk of nausea and post-operative respiratory complications. Thus the health care system will save substantial dollars. In this regard, the cost to the health care system of operating room and recovery area time is approximately $5.00 (Canadian Dollars) and $2.00 (Canadian Dollars) per minute respectively. The total number of anaesthetics given in North America is approximately 35,000,000/year (3.5 million and about 30 million in the United States), a conservative estimate with as high as about 50,000,000/year. The North American estimate does not include Mexico or countries in Central America. A modest average decrease in recovery time in the operating time and in the recovery room of 5 minutes each can potentially result in billions of dollars savings per year worldwide. In North America alone, the expectation of saving 5 minutes in each of the operating room and recovery area can amount to $1,000,000,000 in savings.
It is therefore an object of this invention to provide an improved breathing circuit or circuit components that can be added to a standard circle anaesthetic circuit to be used to hasten recovery of patients who have been administered vapour anaesthetics.
It is a further object of the invention to provide methods of treatment using the said circuit and the use of the said circuit during the administration of vapour anaesthetics to hasten recovery of the said patients.
Further and other objects of the invention will be realized by those skilled in the art reading the following summary of the invention and detailed description of embodiments thereof.
According to one aspect of the invention, there is provided a new breathing circuit and components thereof that can, for example, be added to a standard circle anaesthetic circuit for hastening the recovery of patients administered vapour anaesthetics.
In accordance with the invention, the said circuit and components thereof, when combined with the general anaesthetic circle circuit cause the administration of carbon dioxide gas to the patient to maintain the same PCO2 in the patient independent of the rate of ventilation (so long as the said rate of ventilation is greater than a control rate of ventilation) but permit the rate of anaesthetic vapour elimination from the lungs of the patient to vary directly as the total ventilation by the patient, whether the patient is breathing normally or is hyperventilating. Thus, the vapour anaesthetic is eliminated from the lungs. However, the carbon dioxide is not eliminated from the lungs at a rate greater than the resting rate of the patient or a predetermined control rate. (The predetermined rate of elimination of CO2 may be set based on the rate of administration of the fresh gas into the circuit as discussed below.)
Thus, according to another aspect of the invention, the simple breathing circuit comprises components which together form the simple-circuit and comprise (a) an exit port from which the gases exit from the circuit to the patient, (b) a non-rebreathing valve which constitutes a one-way valve permitting gases to be delivered to the exit port to be delivered to the patient but which non-breathing valve when the patient breathes into the exit port does not permit the gases to pass the non-rebreathing valve into the portion of the circuit from which the gases are delivered but passes them to ambient or elsewhere, (c) a source of gas (which may be oxygen or air or other gases but does not contain CO2 (air contains physiologically insignificant amounts of CO2) in communication with the non-breathing valve to be delivered through the valve to the patient, (d) a fresh gas reservoir in communication with the source of fresh gas flow for receiving excess gas not breathed by the patient from the source of gas and for storing same and when the patient breathes and withdraws amounts of gas from the source of gas flow also enables the patient to receive gas from the fresh gas reservoir in which the gases have been stored, (e) a reserve gas supply containing CO2 and other gases (usually oxygen) wherein the partial pressure of the CO2 is approximately equal to the partial pressure of the CO2 in the patient""s mixed venous blood, for being delivered to the non-rebreathing valve as required by the patient to make up that amount of gas required by the patient when breathing that is not fulfilled from the gases delivered from the source of gas flow and fresh gas reservoir, the said source of gas and fresh gas reservoir and reserve gas supply being disposed on the side of the valve remote from the exit port.
Preferably a pressure relief valve is in communication with the fresh gas reservoir, in the event that the fresh gas reservoir overfills with gas so that the fresh gas reservoir does not break, rupture or become damaged in any way.
The reserve gas supply preferably includes a demand valve regulator so that where the additional gas is required, the demand valve regulator opens the communication of the reserve gas supply to the non-rebreathing valve for delivery of the gas to the non-breathing valve and where not required the demand valve regulator is closed and only fresh gas flows from the source of fresh gas and from the fresh gas reservoir to the non-rebreathing valve. The source of fresh gas is set to supply fresh gas (non-CO2-containing gas) at a rate equal to the desired alveolar ventilation for the elimination of CO2.
The basic concept underlying my approach is that when breathing increases, the rate of flow of fresh gas (inspired PCO2=0) from the fresh gas flow contributing to elimination of CO2 is kept constant. The remainder of the gas inhaled by the subject (from the reserve gas supply) has a PCO2 equal to that of mixed venous blood, does not contribute to a CO2 concentration gradient between mixed venous blood and alveolar gas, and thus does not contribute to elimination of CO2. If there is access to mixed venous blood (such as if a catheter is present in the pulmonary artery, the mixed venous PCO2 can be measured directly. If there is no possibility of measuring, then an estimation can be made from PETCO2. PETCO2 is determined by measuring the PCO2 of expired using a capnograph usually present or easily available in an operating facility by persons skilled in the art.
In effect, the device passively, precisely and continuously matches the amount of CO2 breathed in by the patient to the amount of total breathing, thereby preventing any perturbation of the arterial PCO2. This is opposed to servo-controllers which are always attempting to compensate for changes. Persons skilled in the art, however, may automate the circuit by using a servo-controller or computer to monitor and deliver the amounts from the reserve gas supply.
According to another aspect of the invention, the new simple breathing circuit is used to treat a patient to enable the patient to recover more quickly from, and to hasten the recovery of the patient after, vapour anaesthetic administration.
According to another aspect of the invention, the use of the said circuit is made in the manufacture of a device to hasten the recovery of patients from administration of vapour anaesthetics.
According to another aspect of the invention, the use of the said circuit is made to hasten the recovery of patients from vapour anaesthetics administration.
According to another aspect of the invention, a method of treatment of an animal (for example, a person) is provided (such as to enable such animal to recover from vapour anaesthetics administration), the method comprising delivering to a patient gases which do not contain CO2 at a specified rate, and gases containing CO2 to maintain the same PCO2 in the animal independent of the rate of ventilation, at the rate of ventilation of the animal which exceeds the rate of administration of the gases which do not contain CO2.
Therefore, when the rate of ventilation of the animal exceeds the rate of delivery to the animal of non-CO2-containing gases inhaled by the animal, the CO2-containing gases inhaled by the animal maintain the PCO2 in the animal constant.
Thus, with respect to the use of the invention to eliminate anaesthetic vapour from the lungs, the total ventilation of combined gases which includes the CO2-containing, and non-CO2 containing, gases act to eliminate vapour from the lungs.
This circuit and methods of treatment can also be used for any circumstance where one wants to dissociate the minute ventilation from elimination of carbon dioxide such as respiratory muscle training, investigation of the role of pulmonary stretch receptors, tracheobronchial tone, expand the lung to prevent atelectasis, and control of respiration and other uses as would be understood by those skilled in the art.
The circuit and methods of treatment may also be used by deep sea divers and astronauts to eliminate nitrogen from the body. It can also be used to treat carbon monoxide poisoning under normal baric or hyper baric conditions. The fresh gas will contain 100% oxygen, and the reserve gas will contain approximately 6% CO2 and approximately 94% oxygen. Neither the fresh gas nor the reserve gas supply will, in this case, contain nitrogen.